Hypertension in Pregnancy 2011.pdf

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T h e n e w e ngl a nd j o u r na l o f m e dic i n e Even in the absence of superimposed preeclampsia, women with chronic hypertension have an increased risk of adverse outcomes. 5 Studies that were performed in Canada, the United States, and New Zealand have indicated that fetal growth restriction (estimated or actual fetal weight,
clinical pr actice Table 1. Common Pharmacologic Therapies for Chronic Hypertension in Pregnancy.* Drug Methyldopa Labetalol Class or Mechanism of Action Usual Range of Dose Comments Centrally acting alpha agonist Combined alpha- and beta-blocker 250 mg to 1.5 g orally twice daily Often used as first-line therapy Long-term data suggest safety in offspring 100–1200 mg orally twice daily Often used as first-line therapy May exacerbate asthma Intravenous formulation is available to treat hyper - tensive emergencies Metoprolol Beta-blocker 25–200 mg orally twice daily May exacerbate asthma Possible association with fetal growth restriction Other beta-blockers (e.g., pindolol and propranolol) have been safely used Some experts recommend avoiding atenolol Nifedipine (longacting) Calcium-channel blocker Hydralazine Peripheral vasodilator 50–300 mg orally in two or four divided doses 30–120 mg orally once daily Use of short-acting nifedipine is typically not recommended, given risk of hypotension Other calcium-channel blockers have been safely used Intravenous formulation is available to treat hypertensive emergencies Hydrochlorothiazide Diuretic 12.5–50 mg orally once daily Previous concerns about increased risk of an adverse outcome are not supported by recent data * The use of angiotensin-converting–enzyme inhibitors or angiotensin-receptor blockers is contraindicated in pregnancy because of the risk of birth defects and fetal or neonatal renal failure. including 28 randomized trials comparing antihypertensive treatment either with placebo or with no treatment showed that antihypertensive treatment significantly reduced the risk of severe hypertension. However, treatment did not reduce the risks of superimposed preeclampsia, placental abruption, or growth restriction, nor did it improve neonatal outcomes. 13 The antihypertensive agent with the largest quantity of data regarding fetal safety is methyldopa, which has been used during pregnancy since the 1960s. In one study, 16 no adverse developmental outcomes were reported during 7.5 years of follow-up among 195 children whose mothers had received methyldopa. Thus, methyldopa is considered to be a first-line therapy in pregnancy by many guideline groups. 17-19 However, methyldopa frequently causes somnolence, which may limit its tolerability and necessitate the use of other agents. In a meta-analysis of randomized trials comparing different antihypertensive agents in pregnancy, the use of beta-blockers resulted in fewer episodes of severe hypertension than the use of methyldopa. 13 Labetalol, a combined alpha- and beta-receptor blocker, is often recommended as another firstline 18 or second-line 17 therapy for hypertension in pregnancy. Although some data have suggested an association between atenolol and fetal growth restriction, 20 this finding has not been reported with the use of other beta-blockers or labetalol, and whether the observed association was attributable to the use of atenolol or to the underlying hypertension is uncertain. Nonetheless, some experts consider it prudent to avoid the use of atenolol during pregnancy. 18 Long-acting calcium-channel blockers also appear to be safe in pregnancy, although experience is more limited than with labetalol. 21 Diuretics were long considered contraindicated in pregnancy because of concern about volume depletion. However, a review of nine randomized trials showed no significant difference in pregnancy outcomes n engl j med 365;5 nejm.org august 4, 2011 441 The New England Journal of Medicine Downloaded from nejm.org at KAISER PERMANENTE on August 4, 2011. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved.
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